Ambulatory Providers

Base rates and reimbursement codes for outpatient services and opioid treatment programs.
Ambulatory Providers
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Overview

The below information is in regards to the base rate codes programs should use when billing Medicaid as well as the rates paid out based on those codes for providing any services covered under New York State Regulation Part 822. General Service Standards for Substance Use Disorder Outpatient Programs. 

The downstate peer group includes New York County, Kings County, Queens County, Richmond County, Bronx County, Nassau, Suffolk, Westchester, Rockland, Putnam, Dutchess and Orange counties. The upstate peer group refers to the rest of New York State (ROS).

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    Ambulatory Patient Group Manual

    Rate codes, procedure codes and service description codes for both fee for service and managed care billing in Outpatient SUD, Opioid Treatment Programs and Integrated Services settings.

     

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Revenue Calculators

OASAS developed the APG Medicaid Revenue Calculator. to simulate Medicaid revenue projections associated with APG pricing. OASAS Certified outpatient programs may use the tool to continuously monitor and update their projected APG Medicaid revenues. Calculator have the base rates for the respective programs/peer groups; and, the application of the phased payments.

 

FREESTANDING PROGRAM CALCULATOR

Hospital-Based Program Calculator

Outpatient Services

Ambulatory Patient Group (APG) and Federally Qualified Health Center (FQHC) base rates and reimbursement codes for certified outpatient clinics or outpatient rehabilitation programs.

Learn more and find guidance pertaining to outpatient Part 822 services, here.

Opioid Treatment Programs

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    Guidance on OTP Bundled Codes & Fees

    Bundled OTP rates have been calculated consistent with the Medicare bundles and are adjusted for regional factors. Effective August 1, 2021, OTPs may elect to bill either bundled rates or APGs so long as they only bill one methodology for a patient in a given week. 

     

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Medication Billing

Guidance on billing Sublocade intramuscular injection and oral buprenorphine in ambulatory settings), as well as billing for Vivitrol for outpatient programs.

Please note that changes to Chapters 69 and 71 of the Insurance Laws of 2016 prohibit prior Insurance authorization for medications for treatment of substance use disorder.

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